To Screen, or Not to Screen?

Expanding screening for Type 2 diabetes and prediabetes sounds like it should be pretty uncontroversial — and, in fact, most diabetes-related organizations support stepping up screening efforts. Last year, a coalition of advocacy groups including the American Diabetes Association, the American Association of Diabetes Educators (AADE), and the American Association of Clinical Endocrinologists endorsed broadening the screening recommendations so that more people can receive treatment or “be referred to low-cost, community-based diabetes prevention programs.” As the Chief Advocacy Officer of the AADE said at the time, an estimated 79 million Americans have prediabetes, while another 7 million have undiagnosed diabetes, and identifying all of these people could go a long way toward reducing diabetic complications such as heart disease, stroke, kidney disease, and impaired vision.

But early detection of diabetes may not always have a dramatic effect on the rate of complications later on, as a recently released study hints. Published in the Annals of Family Medicine, the study looked at people ages 45–75 with recently diagnosed Type 2 diabetes: 206 who came in for diagnosis based on symptoms such as frequent urination, fatigue, infections, or blurred vision; and 359 who were diagnosed after a screening based on family history of diabetes and personal history of risk factors such as heart disease, obesity, hypertension, or gestational diabetes. The study sought to explore whether standard diabetes treatment — which both groups received — would lead to better or worse cardiovascular outcomes in either of the two groups. In theory, diabetes discovered through screening should be less “far along” in the course of the disease than diabetes discovered through symptoms, so researchers wanted to know whether catching diabetes earlier through screening could lead to better outcomes.

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What they found, however, was more complicated. According to a MedPage Todayarticle on the study, the two groups had different characteristics at the beginning of the study: the symptomatic group had higher fasting blood glucose and HbA1c levels, while the screening-detected group had experienced more cases of heart and kidney disease and had higher blood pressure. Participants were followed for an average of seven years. At the end of this period, the researchers found that despite better blood glucose control and a lower rate of using insulin in the screening-detected group, there was no significant difference between the two groups in the rate of heart attack, stroke, or death from cardiovascular disease. While the researchers interpreted these results as positive, since the screening-detected group had shown a greater history of cardiovascular problems at the beginning of the study, they admitted that the results might also be used to argue that screening leads to no better health outcomes in the end.

What do you think — should screening programs for diabetes be expanded? If so, who should pay for them? Should screening only be expanded if it can be shown to lead to better health outcomes? Was your diabetes discovered through routine screening, or did you have symptoms that led to your diagnosis? Did you participate in a screening program early enough to be diagnosed with prediabetes, and if so, do you think this helped delay the onset of diabetes? Leave a comment below!

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jim snell

This is a most interesting and revealing column regrading validity and use of screening.

As one who has spent the last 40 years designing, debugging advanced digital processing and communication systems as well as being a type 2 diabetic for the last 30+ years and in the last 6 years fixing the mess and getting my health back in place; the current methodology and crude tools used to debug diabetes would do Stonehenge proud and why yes screening would be not useless but by and large not very effective.

If the screening was using some 23rd century test tools ( ie a 24/7 chemical analysis pack that could watch body for 24/7 a few days and then the computers of the Starship Enterprise bridge were used to crunch the data and give a Doctor a summarized results and factors needing tuning from insulin levels, hormone activities, intestine, liver and thyroid activities as well as energy balance, glucose saturation levels, etc)
it would be possible to set a human back on track from a number of perspectives. Can screening make a difference – you bet it can.

Had I my liver’s monkyshines been caught, diet(energy balance) and exercise corrected as well as any hormone shortfalls, I firmly believe that I could have structured my life far better and healthier as well as dramatically reduced heart and stroke risk greatly that I have now done 30 years later. Then I believe screening would be extremely beneficial reducing costs, destruction of human bodies, limb’s and organs.

I ended up doing 30 test strips a day and CGMS to elicit the data that enabled my Doctor to come up with the stratagies and approaches to move my body’s operation to a better safer quadrent.

With the only real tool available for the type2 diabetic is the caveman fingerprick glucose meter that if used with sufficient number of tests on a timely basis that feeds back useful information to the human to control his diet and eating, then maybe we have some hope on the benefits of screening.

Given the explosion in Type2 diabetes victims worldwide and the medicare/medicare drug industry have set up a system to reduce usage at the same time to one a day strips for type 2 diabetics, the hope that pre screening has any merit is evaporating out the proverbial window.

Margaret Vernier

I benefited greatly from early detection and wish that everyone had the same opportunity.

I was diagnosed four years ago as pre-diabetic which was quite a surprise because my weight, fasting blood sugar, and A1c were all normal. I felt so healthy that I had volunteered for screening as a potential kidney donor. Said screening included a glucose-tolerance test which medical professionals would not otherwise have thought to administer and insurance would not otherwise have paid for.

After adjusting to the shocking diagnosis, I began improving my diet and exercise habits, and now maintain even better fasting blood sugar and A1c levels. I am still glucose intolerant and may eventually become fully diabetic, but will always feel lucky to have known about my pre-diabetes. Changing my habits has likely delayed the “real” disease and, in the meantime, it is so much easier to live with than full-on Type 2 which runs in my family.

By the way, not every good outcome is easily measured—did I mention that I simply feel better than I did before?

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